Summer 2009
New Provider Administered Drug Program to launch
Effective July 20, 2009, Blue Cross and Blue Shield of Florida (BCBSF) will implement a Provider Administered Drug Program—a reimbursement and utilization management program for specific injectible drugs administered in the physician office setting. The program is designed to ensure the affordability of these services for our members. It encourages the use of lower-cost, medically appropriate alternatives, while maintaining quality of care. This program will be managed with the assistance of ICORE Healthcare, LLC.
Benefits
The Provider Administered Drug Program will provide more accurate expedited claims processing. Moreover, it will reduce the need for documentation and review after the service has been provided. The program supports a buy-and-bill model for reimbursement of injectable drugs and continues to reimburse in excess of Centers for Medicare & Medicaid Services (CMS) rates.
Health Options providers still have the option of either (1) utilizing the buy-and-bill approach, including the new Provider Administered Drug Program reimbursement rates or (2) utilizing the existing drug replacement program offered through Caremark.
At this time, the program does not apply to federal employees enrolled in the Blue Cross Blue Shield Services Benefit Plan or State Employees’ PPO Plan members. Additionally, it does not apply to members of other Blue Cross and Blue Shield plans who access a BCBSF network through BlueCard®.
Pre-service reviews available
Beginning July 20, 2009, physicians may obtain a pre-service review of specific drugs that are administered in the physician office setting. The ordering provider should obtain the pre-service review directly from ICORE through their secure website at www.ICOREHealthcare.com/physician or call ICORE at
(800) 424-4947.
ICORE will perform the pre-service review, on behalf of BCBSF, for the drugs identified below. The drugs include:
Aloxi
Aranesp
Avastin
Epogen/Procrit
Herceptin
Neulasta
Neupogen
A pre-service review does not guarantee payment for services. Payment is contingent upon member eligibility and benefits, based on the terms of your participating provider agreement. If pre-service reviews are not obtained for the applicable drugs, payment for those services may be denied. In such cases, members cannot be held responsible for denied charges.
Pre-service review denials received from ICORE can be appealed by following the instructions on the denial letter. For claim appeals or denials, complete the Provider Appeal Form, available on our website.
Refer to the Provider Administered Drug Program Fast Tracker for additional information. Go to our website at www.bcbsfl.com and click on Physicians & Providers, Tools & Resources. If you have additional questions, call the Provider Contact Center at (800) 727-2227.